1. Establishing Health Services
Gilbert Burnham, MD, PhD
Johns Hopkins University

2. Lecture Outline Section A: Health Needs
Section B: Disease Focus vs. Health Focus
Section C: What Should a Health System Be
Able to Do in Emergencies?
Section D: Manner of Providing Health
Services
Section E: Making Specific Decisions
Section F: How Much of What Is Needed?

3. Section A
Health Needs

4. What are the Health-Related Needs of the Displaced?
When people are displaced to an area, what
would cause them to become ill?
– Diseases they brought with them
– Diseases they acquired locally
– Diseases related to changes in their
circumstances

5. What Health Services Do Displaced Persons Need?
Treatment of diseases and injuries
Prevention of illness via medical means
Primary Prevention
Immunization against measles, meningitis, etc.
Secondary Prevention
Treatment of tuberculosis, leprosy, cholera, etc.
Tertiary Prevention
Rehabilitation of land mine injuries
Continued

6. What Health Services Do Displaced Persons Need?
Provision of health-related services
– Water, food, shelter
Identifying the vulnerable for improved
access to those at risk of disease
A major risk factor is forced dependency

7. Disease Focus vs. Health Focus
Section B
Disease Focus vs. Health Focus

8. Disease Focus vs. Health Focus
Disease focus unable to address issues
Disease is not just the absence of correct
diagnosis and treatment
Disease is the absence of a correct public
health approach looking at all factors which
address health of a community

9. Vicious Cycle of Health Care
Curative services futile if not coupled with
public health measures

10. What Should a Health System Be Able to Do in Emergencies?
Section B
What Should a Health System Be Able to Do in Emergencies?

11. What Should a Health System Be Able to Do in Emergencies?
Overall goals for the health system
– Reduce crude death rates to regional
levels
– Improve health status to regional norms
Continued

12. What Should a Health System Be Able to Do in Emergencies?1
Diagnose and treat common conditions,
especially if life-threatening 2
Active case-finding 3
Maintain adequate resources to sustain
health services 4
Prevention of diseases 5
Measure/analyze activities and results 6
Communicate with and train staff

13. Specific Health Services: Child Health Care
Immunization (EPI) programs
Nutrition
– Promoting breastfeeding
– Growth monitoring
– Selective feedings if necessary
– Micronutrients – vitamin A, iron
Continued

14. Specific Health Services: Child Health Care
Treat childhood illness (IMCI approach)
Standard treatment protocols

15. Specific Health Services: General Curative Care
Common diseases
– Priorities, e.g.,
measles, ARI
– Trauma and
fractures
– Chronic diseases,
e.g. TB, asthma
In mid-level
development countries
– Diabetes,
hypertension, heart
disease, arthritis
Continued

16. Specific Health Services: General Curative Care
Provision for outpatient and inpatient care
Prescription of drugs in an acceptable
manner

17. Specific Health Services: Reproductive Health Care
Care during pregnancy
– Provide for safe delivery
Family planning
Care during delivery
Post delivery/post abortion care
STI treatment
HIV prevention
– Testing and counseling

18. Developing the Program

19. Setting of Mission Identification of needs
– Should be specific and quantified
wherever possible
– Needs will serve as basis for monitoring
program impact

20. Developing the Program
Continued

21. Developing the Program

22. Clear Objectives are Basis of Strong Programs
Objectives must be measurable
– Indicators for each must be easily
assessed

23. Developing the Program

24. Developing the Program

25. Strategies Formulated to Implement Objectives
Clear series of tasks set out
Required resources identified
Task A →Task B →Task C
↑ ↑
Input Input

26. Developing the Program

27. Developing the Program

28. Evaluation Based on Objectives
Are the objectives the correct ones?
Have they been reached?
Is there clear evidence of impact?
How will the program be altered based on
the information?

29. How to Establish Services for a Displaced Population
Think through the development of health
system from the first
– “Since x is present, we will do y”
– “If f occurs then g will be needed”

30. Apply the Planning Cycle

31. Carry out a Systematic Assessment
Identify all obvious health problems
– Some for immediate attention
– Others for subsequent attention

32. Decide on Immediate Priorities for Treatment
The 2 X 2 table:
Frequency of disease
diagnosis
High
Low
Risk of serious
illness or death

33. Consider Consequences of Not Addressing the Problem
Consider the consequence of . . .
– Low immunization coverage for measles
– Low immunization coverage for BCG
– Large population in known cholera area
– Widespread scabies or lice
– Large adolescent population

34. Involve Affected Community
Seek refugee community participation
– In priority selection
– In program design
This will promote program ownership

35. Consider Alternatives and Select Appropriate Solution
Use decision matrix to select the potentially
most feasible and effective solution
Solution A B C D
Feasibility
Acceptance
Cost
Sustainability
TOTAL SCORE

36. Set Objectives to Reflect Possible Events
Set program objectives
for program monitoring
and evaluation
– Short-term
objectives
– Longer-term
Ensure objectives are
“SMART”
– Simple
– Measurable
– Attainable
– Realistic
– Time-bound

37. Determine Strategy and Establish Monitoring System
Determine strategy and methods
Implement program
Use information system to monitor process,
outputs and outcomes, as capacity allows
INPUTS →
PROCESS
→ OUTPUTS → OUTCOME

38. Manner of Providing Health Services
Section D
Manner of Providing Health Services

39. In What Manner Should Health Services Be Provided?
Health care is based on Primary Health Care principles
PHC seeks to do the following:
– Provide acceptable and affordable health
care
– Provide optimum rather than maximum
health care

40. Themes of PHC Education about main health problems
– Including prevention and control
Promotion of food supply and proper
Nutrition
Adequate supply of safe water and basic
Sanitation
Maternal and child health care, including
family planning
Continued

41. Themes of PHC Immunization against major diseases
Prevention and control of locally endemic
diseases
Appropriate treatment of common
diseases/injuries
Provision of essential drugs

42. Different Levels of Health Care By Frequency of Needs

43. Resources Required to Provide Health Care

44. Making Specific Decisions
Section E
Making Specific Decisions

45. Specific Decisions to Be Made
Establish new services vs. augment existing services
Where possible, the choice is to strengthen
local services

46. Deciding Whether to Strengthen Local Services
Hospital Level
New facilities very costly
Health Center Level
New facilities often needed
Health Post
New facilities usually needed
Community Services
Specific for displaced populations

47. Setting Staff Requirements
Staff requirements depend on the following:
– Skills and capacity
– Main tasks to be done
– Resource requirements for each
Selection of staff
– Refugee vs. National vs. Expatriate
– Seconded government staff
Continued

48. Setting Staff Requirements
Need personnel policies for the following:
– Job descriptions
– Contracts
– Disciplinary procedures

49. Establishing a Drug Program
Follow Essential Drugs Programme (1977)
Set drug procurement guidelines
Define drug selections for various levels of
health care
Promote “rational” prescribing habits
– Organizational practices
– Host country policy

50. Drug Donations Donated drugs often a disaster in themselves:
– Inappropriate or unknown medications
– Outdated
– Unreadable instructions
– Clutter up warehouses, take up
personnel time

51. New Emergency Health Kit
Contains drugs and medical supplies for
10,000 persons for three months
– 10 basic units for PHC workers
– One supplementary unit for higher-level
workers
Continued

52. New Emergency Health Kit
Does not cover all drug requirements
– Chronic diseases
– Psychotropic drugs

53. How Much of What is Needed?
Section F
How Much of What is Needed?

54. First Referral Hospital
Capacity—1:150,000–300,000
Services provided
– Emergency surgery
– Emergency obstetrical care
– Blood banking
– Basic laboratory
Continued

55. First Referral Hospital
Key staff
– At least two medical officers
– Adequate nursing staff (20+)

56. Health Center Capacity—1:30,000 or 10 km radius
Staffing—health care workers, nurses,
±medical officer, ±simple laboratory
May have inpatient beds and a maternity unit
– Refer to 1st level hospital

57. Health Posts or Dispensaries
Capacity—1:10,000 persons
Referral to the health center
Key staff—medical auxiliaries (primary
health care workers)
– Community Health Workers (CHWs) or
home visitors

58. CHWs Work out of Health Posts
Often refugees—1:500 or 1:1000
Supervision from health post
Duties include the following:
– Health promotion
– Seek out and refer ill persons
– Treat common illness—
e.g., diarrhea
– Refer seriously ill to hospital

59. How Health Services Are Utilized
Initially, may be a rush for treatment
– Pent-up demand
– Epidemics may be in progress
– 2–3% of population may use services/day
Continued

60. How Health Services Are Utilized
Steady state usually 1% of population
visiting OPD services daily
– 1% of outpatient attendance will need
inpatient care
– 1% of inpatients will need hospital
referral

61. Factors Affecting Utilization
Utilization by geographic location
– OPD attendance drops by 50% for every
three km
Continued

62. Factors Affecting Utilization
Utilization by age
– Under-15s constitute 50% or more of
most developing country populations
– Under-5s constitute about 20%
and represent 50–60% of outpatients

63. What Can Health Workers Do?
POTENTIAL CAPACITY
CHW or home visitor
(community-based)
30 persons per day
Medical assistant or nurse
(facility based)
50 persons per day
Medical Officer (doctor)
40 outpatients a day

64. Source of Staff Refugee and host country nationals wherever possible
– Have better understanding of refugee
experiences
Potential for conflicts over pay are great
Establishing credentials of refugee staff may
be difficult

65. Consider “Down Time” for Staff
Remember “down time”
– Training
– Vacation time
– Sick leave and maternity leave
– Rest and relaxation for expatriate staff
– Consider staff turnover

66. Handing Over of Programs
Common after early phase to close down or hand over health services
– To development-oriented NGOs
– Sometimes to host country MoH
Continued

67. Handing Over of Programs
Imperative to design programs for long-term
efficiency from the beginning
Monitoring of program effectiveness
– Measured against set objectives
– Goal to contribute to development of
refugees and host country system
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